We are pleased that you will be having your surgical procedure with us, and are confident that you will have the very best surgical experience possible.
F.A.Q.’s Anesthesia Services
The anesthesia services bill is separate from the surgical and hospital fee. Your insurance company will be directly billed for our services (if procedure is covered by insurance). In some cases the patient will never see the bill for our services. In others, there may be a small co-payment or deductible due.
Many studies done in the early 1990’s have shown that clear liquids empty rapidly from the stomach and need not be held for the usual eight hours prior to surgery. The current fluid and solid food policy is as follows:
No solid food after midnight, the day of surgery.
Unlimited amounts of only water is allowed up to two hours before arrival at Riverside.
Juices, soda pop, coffee and all other clear liquids are not allowed.
There is no volume limitation to the amount of liquids.
If you are called by the operating room for an earlier than scheduled arrival, you can have your water only up to the time of the call.
In house patients are commonly given a small dose of sedative prior to transport to the operating room suites, if appropriate. Outpatients or same day admission surgery patients can be given small intravenous doses of sedation in the preoperative area. Our usual choice is versed which is a short acting drug similar to valium.
An intravenous line is placed prior to surgery in all patients who receive anesthesia. The line is used during surgery to administer medications and fluids. The skin is numbed prior to placement to minimize discomfort.
Given the possibility of infectious transmission (hepatitis, AIDS, etc), blood products are given only if absolutely necessary. The decision to give blood is determined by many factors. A young healthy person is able to tolerate anemia (decreased blood counts) better than an elderly person with heart disease. We would therefore allow the healthy patient to loose more blood before transfusing. We can follow the blood counts during surgery to help us decide when to transfuse. The possibility of transfusion is higher in procedures that might involve significant blood loss such as spine fusion and open heart surgery. Techniques such as recycling your blood (cell saver) and pre -donation of your blood before surgery reduce the possibility of foreign blood transfusion.
It is important to inform your surgeon of this preoperatively. At Riverside we have a special cart stocked with latex free equipment. One important item is latex free surgical gloves. Latex allergy would be suggested by allergic symptoms (runny nose, itchy eyes, wheezing) during:
Blowing up balloons
Contact with condoms or diaphragms
Rectal or gynecological exams
Exposure to rubber gloves
Please let your anesthesiologist know if you have such symptoms.
The awakening process begins when the gases are discontinued at the conclusion of surgery. The time to full arousal will depend in part on the length of the procedure. Most patients can follow commands within 10 minutes and are fairly awake within an hour. Due to the residual effects of all the drugs, important decisions should not be made in the first 24 hours after general anesthesia.
Patients become very drowsy under sedation and unconscious under general anesthesia. We never hear any sensitive information revealed.
Under general anesthesia we are guided by careful monitoring of your vital signs such as blood pressure, heart rate and respiratory rate. Increases in the preceding signs would indicate light anesthesia and the dose would be increased. The careful balance of drug dose to level of stimulus allows for more rapid emergence at the end of the procedure. The doses of local anesthetics in spinal or epidural blocks are guided in part by the height of the patient. For many nerve blocks the dose is guided by body weight.
The final choices would be a function of the procedure done. For example, a wrist fusion requiring hip bone graft would be best done under general anesthesia. Here is a list of the common techniques
Monitored Anesthesia Care (MAC). This is local anesthesia with intravenous sedation. This works well for superficial surgeries such as carpal tunnel repair.
The technique in which local anesthesia is injected into the veins of the arm is a Bier Block. The local anesthetic is held in the arm by inflation of a blood pressure cuff around the biceps. This block works well for procedures lasting under one hour.
The nerves that supply your arm originate from a complex web of nerves known as the brachial plexus. The technique of axillary block involves the numbing of these nerves under your arm. Blockade of these nerves in your neck is known as a supraclavicular block. One advantage of these blocks is the ability to provide analgesia into the post-operative period via use of long acting local anesthetics. These techniques are more suited to complex hand procedures.
Anesthetic drugs are unique in that they are seldom used outside of the operating room setting. For induction of general anesthesia, the intravenous agent propofol is commonly used. It is shorter acting and associated with less nausea and vomiting compared with the many other choices. The general anesthetic state is maintained with a mixture of gases and intravenous agents. The trade names of the gases are forane, suprane and sevoflurane. They are administered from machines called vaporizers. Other classes of drugs are also used. Narcotics are given as an adjuvant to the inhaled gases. The common ones used include morphine, dilaudid, fentanyl and sufentanyl. To facilitate the placement of the breathing tube after anesthetic induction, a muscle relaxant is given. There are many brand names and common ones used include succinylcholine, rocuronium and vecuronium. The use of succinylcholine can result in muscle pains postoperatively (myalgias).
This will vary with the procedure. Patients who have had minor outpatient procedures can eat and drink as tolerated after discharge. You should start with fluids and progress to a full meal. In cases such as major abdominal surgery, you cannot eat or drug until your bowel function returns to normal. This can take longer than 24 hours.
This is question bound to stir up controversy. Many procedures such as heart surgery can only be done under general anesthesia. Peripheral procedures such as knee arthroscopy could be done under general or spinal/epidural. There have been many studies in the anesthesia literature examining the general vs. regional question. Most show no difference in outcome. The final choice will rest on the patient preference and type of procedure. In the case of knee arthroscopy some patients prefer to remain awake so they can watch the procedure on the monitor. This is the perfect case to use a spinal or epidural. Outpatients can’t be discharged home until the block has totally worn off. This a one major disadvantage of regional in this type of case. The possibility of headache after spinal anesthesia is another issue. Your anesthesiologist will be glad to discuss the risks and benefits of regional versus general for the planned surgery.
As an inpatient you will be seen postoperatively by either our postoperative follow up nurse or your anesthesiologist. Any complications are reported to the anesthesiologist for further action. Outpatients are contacted by the hospital postoperatively. Again any complications are reported back to our group. Patients with emergent postoperative anesthetic concerns may call the Riverside operator at (614) 566-5000 and ask for the anesthesiologist on call.
Planning for post-operative pain control begins during your surgery. There are multiple techniques to minimize pain.
Local anesthetics can be injected into the surgical site at the end of the procedure.
Intravenous agents such as narcotics and anti-inflammatory drugs are carefully dosed in the operating room and recovery room.
An epidural catheter can be placed prior to surgery. Postoperatively, dilute solutions of narcotics and/or local anesthetics are dosed through the catheter. This technique is utilized commonly in major vascular surgery procedures. The epidural is left in up to 72 hours postoperatively.
Narcotics can be injected with local anesthesia as part of a spinal anesthetic. We use this technique with many of the radical prostate operations.
A patient controlled analgesia pump (PCA for short) allows for self-medication. This device features a wrist watch like pump which delivers small doses of narcotic according to patient demand. The dosage amounts are adjusted in the device to prevent overdose.
Most often pain is controlled by several of the above approaches at once.
Special thanks to Lisa Smith, R.N. for this additional information.
A member of the anesthesia care time will be with you at all times in the operating room. This is a standard of care in our corporation. Postoperatively, in the recovery room a registered nursed will provide your care. Your will still be under the supervision of an anesthesiologist.
As indicated in the first question, the most severe complication, death is very rare. The rate of other complications will vary with the health status of the patient and the magnitude of the procedure. The common side effects of general anesthesia include nausea, sore throat from the breathing tube, dental damage, muscle aches and shivering postoperatively. Side affects of regional anesthetics such as spinal and epidural anesthesia include spinal headache, nerve irritation, rare infection and back pain.
The monitors we use under general anesthesia depend on both the type of operation and the patient’s medical condition. The minimal monitors under general anesthesia include: blood pressure, EKG, heart rate ,temperature, stethoscope and two monitors of breathing. The pulse oximeter(placed on the fingertips) measures the oxygen saturation of hemoglobin (oxygen carrier) in your blood. This monitor has markedly improved the safety of anesthesia. The other monitor of breathing measures the carbon dioxide in your exhaled breath (capnometer). It helps us in adjustments of the respirator. For more complex procedures such as open heart surgery additional monitors of circulation such as continuous blood pressure and heart pressures. Your anesthesiologist will discuss placement of any invasive monitors with you prior to surgery.
Malignant hyperthermia (MH for short) is a rare genetic disorder characterized by extreme body temperature elevation under general anesthesia. The incidence in adults is about 1 in 50,000 general anesthetics. Certain drugs such as the inhalation anesthetics and the drug succinylcholine are common triggers of this hypermetabolic state. The drug dantrolene is the antidote to this process. With dantrolene and other treatment measures the mortality has been decreased from 80% to 10%. Both Riverside and the Upper Arlington Surgery Center keep fresh supplies of this drug on hand for such an emergency. In patients with known MH or strong family histories, the triggering drugs are avoided during anesthesia. Since there is a strong inherited component, please let us know during the preoperative interview of MH in your family. For more information consult the Malignant Hyperthermia Association of the United States (MHAUS) web site: www.mhaus.org.
Anesthesia depresses the normal gag reflex that prevents solids and liquid matter from entering our lungs. The process of reflux of material from the stomach into the trachea and lungs is called aspiration. Fortunately, the incidence is quite low. According to recent studies, the rate is between 1-5 per hundred thousand anesthetics. Assuring that the stomach is as empty as possible prior to anesthesia is a mainstay in aspiration reduction. This has been routinely accomplished by nothing to eat or drink after midnight, the day of surgery (NPO after midnight). In emergency operations, patients obviously have not fasted. In these cases we can alter the anesthetic delivery and induction to insure maximum safety .
Nausea and vomiting represent one of the most common side effects of anesthesia with an incidence of 20% to 30%. This is better than the days of ether anesthesia where the rate was over 50%. A previous history of PONV , female sex , young age, obesity and type of surgical procedure influence the incidence. New drugs such as zofran are effective in combating this side effect. If you have had a serious problem with nausea and vomiting, please stress this at the preoperative interview. Your anesthetic plan will take this into account.
Despite the media attention the incidence of recall of events under general anesthesia remains a rare event. In the United States, the incidence is 30,000 cases per 15 million cases of general anesthesia per year or 0.2%. It is most common in cases where inhalation agents are given in reduced doses: trauma, cardiac anesthesia and obstetrics. Recently, a new monitor called the BIS has been released for general use. It monitors level of consciousness via analysis of your brain waves. We have 20 BIS monitors at Riverside and they represent a good tool to prevent awareness. Any case of awareness, is taken very seriously by MPAS. You can find out more about the BIS monitor at www.aspectms.com.
Serious complication rates have dramatically improved over the past 40 years. In the 1950’s the rate was 1:1560 anesthetics. The current rate ranges from 1:10,000 to 1:200,000. This decrease is a result of better drugs, equipment and personnel.